HUD-50111-A Section 184-A Addendum to Uniform Residential Loan Appli

Section 184-A Addendum to Uniform Residential Loan Application

OMB Approval No.
(Expires)

Part I – Identifying Information
3. Borrower's Name & Present Address (Include zip code)

1.

7. Property Address (including name of subdivision, lot & block no. &
zip code)

2. Lender’s Loan No.

1. Section 184A Case No.

2.

4. Loan Amount (include
financed guarantee fee)

5. Interest Rate

$

6. Proposed
Maturity

%

8. Lender’s I.D. Code

11. Lender's Name & Address (include zip code)

yrs.
9. Sponsor / Agent I.D.
Code
mos.

10. Name & Address of Sponsor / Agent

12.Lender's Telephone Number
Type or Print all entries clearly

13. First Time
Homebuyer?
Yes
No

14. Purpose of Loan
1)

Purchase Existing Home Previously Occupied

2)

Purchase / Rehabilitation of Existing Property

3)

Rehabilitation of Existing Property

4)

Purchase Existing Home Not Previously
Occupied
– New, Less than 1-year old

5)

Single Close Proposed New Construction

6)

Credit Qualifying No Cash-out Refinance

7)

Credit Qualifying Cash-out Refinance

8)

Credit Qualifying Refinance with construction escrow

9)

Streamline Refinance with Appraisal

10)

Streamline Refinance without Appraisal

11)

Refinance New – Less than 1-year old

Part II - Lender’s Certification
15. The undersigned lender makes the following certifications to
allow issuance of a firm commitment for a loan guarantee under
the Housing and Community Development Act of 1992.
A. The loan terms furnished in the Uniform Residential Loan
Application and this Addendum are true, accurate and complete.
B. The information contained in the Uniform Residential Loan
Application and this Addendum was obtained directly from the borrower
by an employee of the undersigned lender or its duly authorized agent
and is true to the best of the lender’s knowledge and belief.
C. The credit report submitted on the subject borrower (and coborrower, if any) was ordered by the undersigned lender or its duly
authorized agent directly from the credit bureau which prepared the report
and was received directly from said credit bureau.
D. The verification of employment and verification of deposits were
requested and received by the lender or its duly authorized agent
without passing through the hands of any third persons and are true to
the best of the lender’s knowledge and belief.
E. The Uniform Residential Loan Application and this Addendum were
signed by the borrower after all sections were completed.

F. This proposed loan to the named borrower meets the
income and credit requirements of the governing law in the
judgment of the undersigned.
G. To the best of my knowledge and belief, I and my firm
and its principals: (1) are not presently debarred,
suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transactions by any
Federal department or agency; (2) have not, within a threeyear period preceding this proposal, been convicted or had a
civil judgment rendered against them for (a) commission of
fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State
or local) transaction or contract under a public transaction;
(b) violation of Federal or State antitrust statutes or
commission of embezzlement, theft, bribery, falsification or
destruction of records, making false statements, or receiving
stolen property; (3) are not presently indicted for or
otherwise criminally or civilly charged by a governmental
entity (Federal, State or local) with commission of any of
the offenses enumerated in paragraph G(2) of this
certification; (4) have not, within a three-year period
preceding this application/proposal, had one or more public
transactions (Federal, State or local) terminated for cause or
default; and (5) is in compliance with Executive Orders
11063 and 12892 (27 FR 11527 and 59 FR 2939) and
HUD’s Equal Access Rule by complying with HUD
regulations at 24 CFR parts 107 and 121, except as
authorized under Federal law, and with 24 CFR
5.105(a)(2), respectively.

Page 1 of 5

Form HUD-50111-A (date)

Part III - Lender Requirements for Properties located in the Waikoloa Maneuver Area Formerly
Used Defense Site
T the lender must ensure the following requirements are met for properties located within the Waikoloa Maneuver Area Formerly Used Defense Site
(WMA-FUDS) on the island of Hawaii. These requirements are in effect until a site closure letter or comparable document is issued by the State of
Hawaii’s Department of Health (HDOH) declaring the area, or specific properties, safe for residential use.
New ground-disturbing activities will not be allowed until a site closure letter is issued, except in an imminent emergency situation with certain
conditions. Work to avoid an imminent emergency is permitted in the WMA-FUDS if it is done in accordance with any HDOH requirements as well as
the following:

Any surface or subsurface activity must include notification, in advance of the planned activity, of the U.S. Army Corps of Engineers (USACE)
Honolulu District Office, HDOH, and the respective HUD program office;

Any surface or subsurface activity must be done with qualified unexploded ordnance (UXO) personnel and equipment in accordance with
Department of Defense Explosive Safety Board Technical Paper 18; and

If subsurface activity is planned, provisions must be made to detect and remove UXO at a depth of at least 12” greater than the planned depth
of excavation.
New non-ground disturbing activities will be allowed with certain conditions in project sites where the USACE has removed UXO from the surface
and/or the land surface is covered with permanent impervious surfaces such as buildings and roads. Conditions include:

Notice to lessee, purchaser, or recipient that the property is in the WMA-FUDS prior to lease signing, closing on purchase, or commencing
rehabilitation;

New title transfers must include deed notice of property location in WMA-FUDS and deed restrictions on disturbing covered surfaces until a
site closure letter is issued; and

Ensure written public education materials are provided, and community-wide public education programs are utilized.
New non-ground disturbing activities will not be allowed in project sites where USACE has not removed UXO from the surface or the land surface is not
covered, until a site closure letter is issued.
The lender must ensure that notice and public education materials are provided to land owners and residents of existing HUD-assisted properties
located within the WMA-FUDS. All proposed new activities on these sites must comply with the above requirements.
The undersigned lender understands and agrees that it is responsible for the omissions, errors, or acts of its agents associated with Parts II and III, as
described above.
Signature of Officer of Lender

Title of Officer of Lender

Date (mm/dd/yyyy)

______________________________________________________________________________
Part IV - Notices to Borrowers
The information requested on the Uniform Residential Loan Application and this Addendum is authorized by 12 U.S.C. 1701 et seq.. The Debt
Collection Act of 1982, Pub. Law 97-365, and HUD’s Housing and Community Development Act of 1987, 42 U.S.C. 3543, require persons applying for a
federally insured or guaranteed loan to furnish his/her social security number (SSN). You must provide all the requested information, including your
SSN. HUD may conduct a computer match to verify the information you provide. HUD may disclose certain information to Federal, State and local
agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not otherwise be disclosed or released outside of HUD,
except as required and permitted by law. The information will be used to determine whether you qualify as a mortgagor. Any disclosure of information
outside of HUD will be made only as permitted by law. Failure to provide any of the requested information, including SSN, may result in disapproval of
your loan application. This is notice to you as required by the Right to Financial Privacy Act of 1978 that HUD has a right of access to financial
records held by financial institutions in connection with the consideration or administration of assistance to you. Financial records involving your transaction
will be available to HUD without further notice or authorization but will not be disclosed or released by this institution to another Government Agency or
Department without your consent except as required or permitted by law. Delinquencies, defaults, foreclosures and abuses of mortgage loans involving
programs of the Federal Government can be costly and detrimental to your credit, now and in the future. The lender in this transaction, its agents and
assigns as well as the Federal Government, its agencies, agents and assigns, are authorized to take any and all of the following actions in the event
loan payments become delinquent on the mortgage loan described in the attached application: (1) Report your name and account information to a
credit bureau; (2) Assess additional interest and penalty charges for the period of time that payment is not made; (3) Assess charges to cover
additional administrative costs incurred by the Government to service your account; (4) Offset amounts owed to you under other Federal programs;
(5Refer your account to a private attorney, collection agency or mortgage servicing agency to collect the amount due, foreclose the mortgage, sell the
property and seek judgment against you for any deficiency; (6) Refer your account to the Department of Justice for litigation in the courts; (7) If you are
a current or retired Federal employee, take action to offset your salary, or civil service retirement benefits; (8) Refer your debt to the Internal Revenue
Service for offset against any amount owed to you as an income tax refund; and (9) Report any resulting written-off debt of yours to the Internal
Revenue Service as your taxable income. All of these actions can and will be used to recover any debts owed when it is determined to be in the
interest of the lender and/or the Federal Government to do so.

Form HUD-50111-A (date)

Part V - Borrower Consent for Social Security Administration to Verify Social Security Number
I authorize the Social Security Administration to verify my Social Security number to the Lender identified in this document and HUD, through a
computer match conducted by HUD. I understand that my consent allows no additional information from my Social Security records to be provided to
the Lender and HUD, and that verification of my Social Security number does not constitute confirmation of my identity. I also understand that my
Social Security number may not be used for any other purpose than the one stated above, including resale or re-disclosure to other parties. The
only other re-disclosure permitted by this authorization is for review purposes to ensure that HUD complies with SSA's consent requirements. I am
the individual to whom the Social Security number was issued or that person's legal guardian. I declare and affirm under the penalty of perjury that the
information contained herein is true and correct. I know that if I make any representation that I know is false to obtain information from Social Security
records, I could be punished by a fine or imprisonment or both. This consent is valid for 180 days from the date signed, unless indicated
otherwise by the individual(s) named in this loan application.

Read consent carefully. Review accur acy of social security number(s) and birth dates provided on this application.
Signature(s) of Borrower(s)

Date Signed (mm/dd/yyyy)

Signature(s) of Co-Borrower(s)

Part VI – Borrower Certification

16b. Is it to be sold?

16a. Do you own or have you sold other real estate within the past 24 months
on which there was a mortgage?

Yes

No

Date Signed
(mm/dd/yyyy)

16c. If Yes, was the mortgage a Section 184A
guaranteed loan?
Yes

No

Yes
No
17. As a home loan borrower, you will be legally obligated to make the mortgage payments called for by your mortgage loan contract. The fact that you
dispose of your property after the loan has been made will not relieve you of liability for making these payments. Payment of the loan in full is ordinarily
the way liability on a mortgage note is ended. Some home buyers have the mistaken impression that if they sell their homes when they move to
another locality, or dispose of it for any other reasons, they are no longer liable for the mortgage payments and that liability for these payments is solely
that of the new owners. Even though the new owners may agree in writing to assume liability for your mortgage payments, this assumption agreement
will not relieve you from liability to the holder of the note which you signed when you obtained the loan to buy the property. Unless you are able to sell
the property to a buyer who is acceptable to HUD and who will assume the payment of your obligation to the lender, you will not be relieved from liability
to repay any claim which HUD may be required to pay your lender on account of default in your loan payments. The amount of any such claim payment
will be a debt owed by you to the Federal Government. This debt will be the object of established collection procedures.
18. I, the Undersigned Borrower(s) Certify that:
(1) I have read and understand the foregoing concerning my liability on
the loan and Part III Notices to Borrowers.
I have been informed that ($
) is the statement
of appraised value as determined by HUD.
Note: If the contract price or cost exceeds the value established on the
Uniform Residential Appraisal Report, mark either item (a) or item (b),
whichever is applicable.
 (a) I was aware of this valuation when I signed my contract and I have
paid or will pay in cash from my own resources at or prior to loan closing
a sum equal to the difference between the contract purchase price or
cost and the HUD established value. I do not and will not have
outstanding after loan closing any unpaid contractual obligation on
account of such cash payment;
 (b) I was not aware of this valuation when I signed my contract but
have elected to complete the transaction at the contract purchase price
or cost. I have paid or will pay in cash from my own resources at or prior
to loan closing a sum equal to the difference between contract purchase
price or cost and the HUD established value. I do not and will not have
outstanding after loan closing any unpaid contractual obligation on
account of such cash payment.

(2) Neither I, nor anyone authorized to act for me, will refuse to sell, after
the making of a bona fide offer, or refuse to negotiate for the sale of, or
otherwise make unavailable or deny the dwelling or property covered by
his/ her loan to any person because of race, color, religion, sex,
handicap, familial status or national origin. I recognize that any restrictive
covenant on this property relating to race, color, religion, sex, handicap,
familial status or national origin is illegal and void and civil action for
preventive relief may be brought by the Attorney General of the United
States in any appropriate U.S. District Court against any person responsible for the violation of the applicable law.
(3) All information in this application is given for the purpose of obtaining
a loan to be guaranteed under Section 184A of the Housing and Community
Development Act of 1992 and the information in the Uniform Residential
Loan Application and this Addendum is true and complete to the best of my
knowledge and belief. Verification may be obtained from any source named
herein.
(4) For properties constructed prior to 1978, I have received information on lead
paint poisoning.
(5) I am aware that HUD does not warrant the condition or value of the
property

Signature(s) of Borrower(s) - Do not sign unless this application is fully completed. Read the certifications carefully & review accuracy of this
application.
Signature(s) of Borrower(s)

Date Signed (mm/dd/yyyy)

Signature(s) of Co-Borrower(s)

Date Signed
(mm/dd/yyyy)

Form HUD-50111-A (date)

Section 184A Addendum to Uniform Residential Loan Application

OMB Approval No.
(exp. )

(Borrowers Must Sign Both Parts V & VI) Federal statutes provide severe penalties for any fraud or intentional
misrepresentation contained on this form.

Borrower's Certificate:
The undersigned certifies that:
(a) I will not have outstanding any other unpaid obligations contracted in connection with the
mortgage transaction or the purchase of the said property except obligations which are secured by
property or collateral owned by me independently of the said mortgaged property, or obligations
approved by the Secretary;
(b) One of the undersigned intends to occupy the subject property for the term of the Section 184A
loan;
(c) All charges and fees collected from me as shown in the settlement statement have been paid by my
own funds (or HUD approved gift funds), and no other charges have been or will be paid by me in
respect to this transaction;
(d) Neither I, nor anyone authorized to act for me, will refuse to sell, after the making of a bona fide
offer, or refuse to negotiate for the sale of or otherwise make unavailable or deny the dwelling or
property covered by this loan to any person because of race, color, religion, sex, handicap,
familial status or national origin. I recognize that any restrictive covenant on this property relating
to race, color, religion, sex, handicap, familial status or national origin is illegal and void and any
such covenant is hereby specifically disclaimed. I understand that civil action for preventative
relief may be brought by the Attorney General of the United States in any appropriate U.S. District
Court against any person responsible for a violation of this certificate.

Borrower(s) Name

Signature of Borrower(s)

Lender's Certificate

Date

:

The undersigned certifies that to the best of its knowledge:
(a) The statements made in its application for insurance and in this Certificate are true and
correct;
(b) The conditions appearing in any outstanding commitment issued under the above case number
have been fulfilled;
(c) Complete disbursement of the loan has been made to the borrower, or to his/her creditors for
his/her account and with his/her consent;
(d) The security instrument has been recorded and is a good and valid first lien on the property
described;
(e) No charge has been made to or paid by the borr ower except as permitted under HUD
regulations;
(f) The copies of the credit and security instruments which are submitted herewith are true and exact
copies as executed and filed for record;
(g) Lender has not paid any kickbacks, fee or consideration of any type, directly or indirectly, to any
party in connection with this transaction except as permitted under HUD regulations and
Form HUD-50111-A
(date)

Section 184A Addendum to Uniform Residential Loan Application

OMB Approval No.
(exp. )

administrative instructions.
I, the undersigned, as authorized representative of
mortgagee at this time of closing of this mortgage loan, certify that I have personally reviewed the
mortgage loan documents, closing statements, application for guarantee endorsemen t, and all
accompanying documents.
Lender’s Name

Title of Lender’s Officer

Signature of Lender’s Officer

Date

Privacy Act Statement. This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The authority
for collecting personally identifiable information (PII) in the Regulatory Consistency Communication Board
(RCCB) Electronic Feedback Form is based in Section 313 of Public Law 112-95.
Public reporting burden for this collection of information is estimated to average .50 hours per response, including
the time for reviewing instructions, searching existing data sources, gather and maintaining the data needed, and
completing and reviewing the collection of information. HUD may not collect this information, and you are not
required to complete this form, unless it displays a currently valid OMB control number.
This information is required in order for an eligible homebuyer to obtain a benefit and for HUD to administer the
Loan Guarantee Program for low-income Native Americans, Alaska Natives, and native Hawaiians (24 CFR
Parts1000 and 6000). The requested information is necessary to determine the income and credit worthiness of low
income homebuyers. If HUD did not collect this information, it would prevent HUD from guaranteeing mortgages
to eligible homebuyers. While no assurances of confidentiality are pledged to respondents, HUD generally discloses
this data only in response to a Freedom of Information request.

Form HUD-50111-A
(date)